A 26-year-old female presented with a history of gradual weight gain since 6 months. She had put on 8 kg and her periods were irregular. She had developed facial hair and acne. She had no past history of thyroid disorder/ diabetes nor was she on any regular medications. On examination, her weight was 76 kg with a BM! of 30 and blood pressure was 140/90 mmHg. She had acne, facial hirsutism, moon face and buffalo hump. There was no goiter. Striae were present on her abdomen.
A diagnosis of Cushings was considered and she was investigated further. An overnight dexamethasone suppression test was done which revealed a failure of suppression of cortisol, indicating cortisol excess. ACTH level was suppressed suggesting adrenal source of the steroid excess. CT abdomen was done which showed a right adrenal adenoma. She underwent an adrenalectomy – 3 months post surgery she had lost 4 kg weight and her facial hair and acne had reduced.
A 30-year-old male was referred to the Endocrinology clinic with history of palpitations, headache and sweating on and off since 3 years. He was diagnosed with high blood pressure and was put on anti-hypertensives. However, his symptoms did not settle and he was, in fact, admitted twice with hypertensive emergency. There was no significant family history. On examination his pulse was 80/min, BP 150/90mmHg. Systemic examination was unremarkable. Thyroid function tests done outside were normal.
A possible diagnosis ofphaeochromocytoma was considered. Plasma free metanephrines and normetanephrines were measured and were markedly elevated. CT abdomen revealed a 3cm left adrenal mass compatible with phaechromocytoma. Appropriate perioperative therapy with alpha blockers was started and he was referred for adrenalectomy. After surgery, blood pressure normalised without any antihypertensives.
Adrenal disorders are rare and as such it is important to diagnose these conditions early as treatment is effective. Hypofunctioning of the adrenal gland (the classical Addisons disease) can present with symptoms of extreme fatigue, hypotension, weight loss, muscle pains and darkening of the skin. On the other hand, excess secretion of cortisol by the adrenal cortex causes Cushings syndrome as was in our first case. Symptoms of this condition include excess weight gain, hypertension, moon face, muscle weakness, back pain and skin changes (easy bruising, acne and purple striae on abdomen and thighs).
Pheochromocytoma is a tumour of the adrenal gland that causes excess release of catecholamines. Hypertension is the most important symptom but tachycardia, excessive sweating and headaches are also seen ( as was in our second case). Another rare adrenal disorder is Conn syndrome. In this condition, there is excess production of aldosterone causing hypertension and is frequently associated with hypokalaemia. Adrenal disorders are an important cause of secondary hypertension and all young and resistant hypertensive patients should be screened for them. Surgery is usually considered when hormone excess is confirmed.